The Economic Potential of Smoking Cessation Interventions at the Point of Diagnosis of Non-Small Cell Lung Cancer.

OBJECTIVES: Stopping smoking has proven benefits in nearly all illnesses but the impact and health economic benefits of stopping smoking after a diagnosis of lung cancer are less well defined. We assessed the cost-effectiveness of smoking cessation (SC) services for patients with newly diagnosed lung cancer against current usual care, where patients are unlikely to receive SC service referral. METHODS: A health economic model was constructed in Excel. The modelled population comprised of patients with a new diagnosis of non-small cell lung cancer (NSCLC). Data from the LungCast data set (Clinical Trials Identifier NCT01192256) were used to estimate model inputs. A structured search of published literature identified inputs not represented in LungCast, including healthcare resource use and costs. Costs were estimated from a 2020/2021 UK National Health Service and Personal Social Services perspective. The model estimated the incremental quality-adjusted life-year (QALY) gained in patients with newly diagnosed NSCLC receiving targeted SC intervention than those receiving no intervention. Extensive one-way sensitivity analyses explored input and data set uncertainty. RESULTS: In the 5-year base case, the model estimated an incremental cost of £14 904 per QALY gained through SC intervention. Sensitivity analysis estimated an outcome range of between £9935 and £32 246 per QALY gained. The model was most sensitive to the estimates of relative quit rates and expected healthcare resource use. CONCLUSION: This exploratory analysis indicates that SC intervention for smokers with patients with newly diagnosed NSCLC should be a cost-effective use of UK National Health Service resources. Additional research with focused costing is needed to confirm this positioning.

Cost of hepatocellular carcinoma to the national health service in England: a registry-based analysis.

OBJECTIVE: Hepatocellular carcinoma (HCC) incidence in the UK trebled between 1997 and 2017. With increasing numbers requiring treatment, understanding the likely impact on healthcare budgets can inform service planning and commissioning. The aim of this analysis was to use existing registry data to describe the direct healthcare costs of current treatments for HCC and estimate the impact on National Health Service (NHS) budgets. DESIGN: A retrospective data analysis based on the National Cancer Registration and Analysis Service cancer registry informed a decision-analytic model for England comparing patients by cirrhosis compensation status and those on palliative or curative treatment pathways. Potential cost drivers were investigated by undertaking a series of one-way sensitivity analyses. RESULTS: Between 1 January 2010 and 31 December 2016, 15 684 patients were diagnosed with HCC. The median cost per patient over 2 years was £9065 (IQR: £1965 to £20 491), 66% did not receive active therapy. The cost of HCC treatment for England over 5 years was estimated to be £245 million. CONCLUSION: The National Cancer Registration Dataset and linked data sets have enabled a comprehensive analysis of the resource use and costs of secondary and tertiary healthcare for HCC, providing an overview of the economic impact to the NHS England of treating HCC.

Development of a resource-use measure to capture costs of diabetic foot ulcers to the United Kingdom National Health Service, patients and society.

Background: Diabetic foot ulcers (DFUs) add a significant burden to the lives of people with diabetes in the United Kingdom. They can have a considerable impact on a patient's daily life, with treatment requiring frequent changes of dressings and clinic attendances. Nurses and other allied health professionals (AHPs) within the community provide most wound care representing the primary cost driver. Aims: To collaboratively explore key resource use related to the management of DFUs to develop, and pilot, a participant-reported measure to inform economic evaluations. Methods: A literature search and semi-structured interviews determined health and non-health resource use in management of DFUs. A consensus view of the selected items was established in a modified Delphi study and further tested for acceptability and validity in a pilot study. Results: Primary care consultations with a podiatrist or orthotist, district nurse visits, out-of-hours and emergency care, scans and investigations, and consumables provided in clinics were rated as the most important resource use items. Conclusions: This work has informed the development of a measure that captures resource use considered important by the people most affected by DFUs; patients, family members and carers, and the healthcare professionals key to DFU management.

Investigating physician self-referral in public hospitals in South East Nigeria: Insights from stakeholders.

BACKGROUND: Physician self-referral occurs where a full-time paid doctor diverts patients from one hospital to another in which he or she has financial interest. AIM: This study is aimed at investigating the views of service users, physicians and policymakers on physician self-referral practice in public hospitals in Nigeria. SETTING: The study was carried out in Enugu urban area of South East Nigeria. METHODS: A mix of qualitative and quantitative methods was used to collect information from different categories of stakeholders. Service user views were explored through analysis of four focus group discussions involving 26 participants and 407 questionnaires completed with household members who had recently visited a public hospital and then gone to private hospitals. In-depth interviews were completed with 15 public sector doctors not involved in dual practice and eight key policymakers. RESULTS: Thirty-four of 407 respondents (8.4%) visiting a public hospital were diverted to a private facility associated with the attending public hospital doctor. The research examined age, gender and socio-economic status (SES) as factors that might influence the likelihood of patient diversion. Advice to transfer to a private clinic usually came directly from the doctor involved but might also come from nurses. CONCLUSION: Physician self-referral in Nigeria could take different forms. It was found that both direct and indirect forms of diversion exist, suggesting that this is an organised practice in which dual-practice doctors and supporting hospital staff members cooperate. The study recommends, among other things, that service users should be adequately protected from any form of diversion to private practice by the public system employee doctors.Contribution: This study contributes to understanding the extent and pattern of patient diversion in public hospitals in Nigeria. The findings reveal coordinated tactics for diverting public hospital patients and provide a direction for future research in negative behaviour among healthcare professionals in Nigeria.

Healthcare resource utilisation and cost analysis associated with opioid analgesic use for non-cancer pain: A case-control, retrospective study between 2005 and 2015.

Objective: To examine differences in healthcare utilisation and costs associated with opioid prescriptions for non-cancer pain issued in primary care. Method: A longitudinal, case-control study retrospectively examined Welsh healthcare data for the period 1 January 2005-31 December 2015. Data were extracted from the Secure Anonymised Information Linkage (SAIL) databank. Subjects, aged 18 years and over, were included if their primary care record contained at least one of six overarching pain diagnoses during the study period. Subjects were excluded if their record also contained a cancer diagnosis in that time or the year prior to the study period. Case subjects also received at least one prescription for an opioid analgesic. Controls were matched by gender, age, pain-diagnosis and socioeconomic deprivation. Healthcare use included primary care visits, emergency department (ED) and outpatient (OPD) attendances, inpatient (IP) admissions and length of stay. Cost analysis for healthcare utilisation used nationally derived unit costs for 2015. Differences between case and control subjects for resource use and costs were analysed and further stratified by gender, prescribing persistence (PP) and deprivation. Results: Data from 3,286,215 individuals were examined with 657,243 receiving opioids. Case subjects averaged 5 times more primary care visits, 2.8 times more OPD attendances, 3 times more ED visits and twice as many IN admissions as controls. Prescription persistence over 6 months and greater deprivation were associated with significantly greater utilisation of healthcare resources. Opioid prescribing was associated with 69% greater average healthcare costs than in control subjects. National Health Service (NHS) healthcare service costs for people with common, pain-associated diagnoses, receiving opioid analgesics were estimated to be £0.9billion per year between 2005 and 2015. Conclusion: Receipt of opioid prescriptions was associated with significantly greater healthcare utilisation and accompanying costs in all sectors. Extended prescribing durations are particularly important to address and should be considered at the point of initiation.

Evaluation of tumour surveillance protocols and outcomes in von Hippel-Lindau disease in a national health service.

BACKGROUND: Von Hippel-Lindau (VHL) disease is an inherited tumour predisposition syndrome and a paradigm for the importance of early diagnosis and surveillance. However, there is limited information on the "real world" management of VHL disease. METHODS: A national audit of VHL disease in the United Kingdom. RESULTS: VHL disease was managed mostly via specialist clinics coordinated through regional clinical genetics services (but frequently involving additional specialties). Over the study period, 19 genetic centres saw 842 individuals (393 males, 449 females) with a clinical and/or molecular diagnosis of VHL disease and 74 individuals (35 male, 39 female) with a prior risk of 50% (affected parent). All centres offered retinal, central nervous system and abdominal surveillance to affected individuals and at-risk relatives though surveillance details differed between centres (but complied with international recommendations). Renal lesions detected on the first surveillance scan were, on average, larger than those detected during subsequent scans and the larger the diameter at detection the greater the likelihood of early intervention. CONCLUSIONS: In a state-funded health care system individuals with a rare inherited cancer predisposition syndrome are generally able to access appropriate surveillance and patient management is improved compared to historical data. The "real world" data from this study will inform the future development of VHL management protocols.

Palliative radiotherapy combined with stent insertion to reduce recurrent dysphagia in oesophageal cancer patients: the ROCS RCT.

BACKGROUND: Most patients with oesophageal cancer present with incurable disease. For those with advanced disease, the mean survival is 3-5 months. Treatment emphasis is therefore on effective palliation, with the majority of patients requiring intervention for dysphagia. Insertion of a self-expanding metal stent provides rapid relief but dysphagia may recur within 3 months owing to tumour progression. Evidence reviews have called for trials of interventions combined with stenting to better maintain the ability to swallow. OBJECTIVES: The Radiotherapy after Oesophageal Cancer Stenting (ROCS) study examined the effectiveness of palliative radiotherapy, combined with insertion of a stent, in maintaining the ability to swallow. The trial also examined the impact that the ability to swallow had on quality of life, bleeding events, survival and cost-effectiveness. DESIGN: A pragmatic, multicentre, randomised controlled trial with follow-up every 4 weeks for 12 months. An embedded qualitative study examined trial experiences in a participant subgroup. SETTING: Participants were recruited in secondary care, with all planned follow-up at home. PARTICIPANTS: Patients who were referred for stent insertion as the primary management of dysphagia related to incurable oesophageal cancer. INTERVENTIONS: Following stent insertion, the external beam radiotherapy arm received palliative oesophageal radiotherapy at a dose of 20 Gy in five fractions or 30 Gy in 10 fractions. MAIN OUTCOME MEASURES: The primary outcome was the difference in the proportion of participants with recurrent dysphagia, or death, at 12 weeks. Recurrent dysphagia was defined as deterioration of ≥ 11 points on the dysphagia scale of the European Organisation of Research and Treatment of Cancer Quality of Life Questionnaire oesophago-gastric module questionnaire. Secondary outcomes included quality of life, bleeding risk and survival. RESULTS: The study recruited 220 patients: 112 were randomised to the usual-care arm and 108 were randomised to the external beam radiotherapy arm. There was no evidence that radiotherapy reduced recurrence of dysphagia at 12 weeks (48.6% in the usual-care arm compared with 45.3% in the external beam radiotherapy arm; adjusted odds ratio 0.82, 95% confidence interval 0.40 to 1.68; p = 0.587) and it was less cost-effective than stent insertion alone. There was no difference in median survival or key quality-of-life outcomes. There were fewer bleeding events in the external beam radiotherapy arm. Exploration of patient experience prompted changes to trial processes. Participants in both trial arms experienced difficulty in managing the physical and psychosocial aspects of eating restriction and uncertainties of living with advanced oesophageal cancer. LIMITATIONS: Change in timing of the primary outcome to 12 weeks may affect the ability to detect a true intervention effect. However, consistency of results across sensitivity analyses is robust, including secondary analysis of dysphagia deterioration-free survival. CONCLUSIONS: Widely accessible palliative external beam radiotherapy in combination with stent insertion does not reduce the risk of dysphagia recurrence at 12 weeks, does not have an impact on survival and is less cost-effective than inserting a stent alone. Reductions in bleeding events should be considered in the context of patient-described trade-offs of fatigue and burdens of attending hospital. Trial design elements including at-home data capture, regular multicentre nurse meetings and qualitative enquiry improved recruitment/data capture, and should be considered for future studies. FUTURE WORK: Further studies are required to identify interventions that improve stent efficacy and to address the multidimensional challenges of eating and nutrition in this patient population. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12376468 and Clinicaltrials.gov NCT01915693. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 31. See the NIHR Journals Library website for further project information.

Most people are diagnosed with oesophageal (gullet) cancer when it is already at an advanced stage. Losing the ability to swallow food and even fluids is very common when patients are approaching the last months of life. Placing a flexible metal tube, or stent, in the gullet opens it up and improves the ability to swallow quickly. Unfortunately this can fail after around 3 months because the cancer grows and presses on the stent. We designed this trial to see if giving a small dose of radiotherapy alongside insertion of the stent would allow more people to remain swallowing well after 3 months. This could then improve their quality of life and reduce hospitalisation towards the end of life. It may also reduce bleeding from the gullet, as well as other symptoms. We recruited 220 people across the UK, randomly assigning them to have the stent as usual or the stent and a low dose of radiotherapy. We collected a lot of information from the participants at home on how the cancer, the stent and the radiotherapy affected their ability to swallow and their quality of life. Overall, the study showed that the radiotherapy did not improve the ability to swallow 3 months following stent insertion and was less cost-effective than stent insertion alone. It seemed to reduce the risk of bleeding from the tumour itself, but patients found that radiotherapy made them tired and attending extra hospital visits could be troublesome. We also learned that, even after a stent was inserted, patients still struggled with food and needed more support with managing daily life with the stent. The trial results are important. They show that, to answer questions such as these, studies should use different ways of assessing what works, particularly focusing on patients' and families' viewpoints. The results will guide doctors to not routinely give radiotherapy in this situation. The results also suggest that, after the insertion of a stent, patients need extra help in managing their diet, their worries about the stent and their worries about the future.

Palliative radiotherapy after oesophageal cancer stenting (ROCS): a multicentre, open-label, phase 3 randomised controlled trial.

BACKGROUND: Patients with advanced oesophageal cancer have a median survival of 3-6 months, and most require intervention for dysphagia. Self-expanding metal stent (SEMS) insertion is the most typical form of palliation in these patients, but dysphagia deterioration and re-intervention are common. This study examined the efficacy of adjuvant external beam radiotherapy (EBRT) compared with usual care alone in preventing dysphagia deterioration and reducing service use after SEMS insertion. METHODS: This was a multicentre, open-label, phase 3 randomised controlled trial based at cancer centres and acute care hospitals in England, Scotland, and Wales. Patients (aged ≥16 years) with incurable oesophageal carcinoma receiving stent insertion for primary management of dysphagia were randomly assigned (1:1) to receive usual care alone or EBRT (20 Gy in five fractions or 30 Gy in ten fractions) plus usual care after stent insertion. Usual care was implemented according to need as identified by the local multidisciplinary team (MDT). Randomisation was via the method of minimisation stratified by treating centre, stage at diagnosis (I-III vs IV), histology (squamous or non-squamous), and MDT intent to give chemotherapy (yes vs no). The primary outcome was difference in proportions of participants with dysphagia deterioration (>11 point decrease on patient-reported European Organisation for Research and Treatment of Cancer quality of life questionnaire-oesophagogastric module [QLQ-OG25], or a dysphagia-related event consistent with such a deterioration) or death by 12 weeks in a modified intention-to-treat (ITT) population, which excluded patients who did not have a stent inserted and those without a baseline QLQ-OG25 assessment. Secondary outcomes included survival, quality of life (QoL), morbidities (including time to first bleeding event or hospital admission for bleeding event and first dysphagia-related stent complications or re-intervention), and cost-effectiveness. Safety analysis was undertaken in the modified ITT population. The study is registered with the International Standard Randomised Controlled Trial registry, ISRCTN12376468, and ClinicalTrials.gov, NCT01915693, and is completed. FINDINGS: 220 patients were randomly assigned between Dec 16, 2013, and Aug 24, 2018, from 23 UK centres. The modified ITT population (n=199) comprised 102 patients in the usual care group and 97 patients in the EBRT group. Radiotherapy did not reduce dysphagia deterioration, which was reported in 36 (49%) of 74 patients receiving usual care versus 34 (45%) of 75 receiving EBRT (adjusted odds ratio 0·82 [95% CI 0·40-1·68], p=0·59) in those with complete data for the primary endpoint. No significant difference was observed in overall survival: median overall survival was 19·7 weeks (95% CI 14·4-27·7) with usual care and 18·9 weeks (14·7-25·6) with EBRT (adjusted hazard ratio 1·06 [95% CI 0·78-1·45], p=0·70; n=199). Median time to first bleeding event or hospital admission for a bleeding event was 49·0 weeks (95% CI 33·3-not reached) with usual care versus 65·9 weeks (52·7-not reached) with EBRT (adjusted subhazard ratio 0·52 [95% CI 0·28-0·97], p=0·038; n=199). No time versus treatment interaction was observed for prespecified QoL outcomes. We found no evidence of differences between trial group in time to first stent complication or re-intervention event. The most common (grade 3-4) adverse event was fatigue, reported in 19 (19%) of 102 patients receiving usual care alone and 22 (23%) of 97 receiving EBRT. On cost-utility analysis, EBRT was more expensive and less efficacious than usual care. INTERPRETATION: Patients with advanced oesophageal cancer having SEMS insertion for the primary management of their dysphagia did not gain additional benefit from concurrent palliative radiotherapy and it should not be routinely offered. For a minority of patients clinically considered to be at high risk of tumour bleeding, concurrent palliative radiotherapy might reduce bleeding risk and the need for associated interventions. FUNDING: National Institute for Health Research Health Technology Assessment Programme.

Examining opioid prescribing trends for non-cancer pain using an estimated oral morphine equivalence measure: a retrospective cohort study between 2005 and 2015.

BACKGROUND: Over the past 20 years prescription of opioid medicines has markedly increased in the UK, despite a lack of supporting evidence for use in commonly occurring, painful conditions. Prescribing is often monitored by counting numbers of prescriptions dispensed, but this may not provide an accurate picture of clinical practice. AIM: To use an estimated oral morphine equivalent (OMEQe) dose to describe trends in opioid prescribing in non-cancer pain, and explore if opioid burden differed by deprivation status. DESIGN & SETTING: A retrospective cohort study using cross-sectional and longitudinal trend analyses of opioid prescribing data from Welsh Primary Care General Practices (PCGP) took place. Data were used from the Secure Anonymised Information Linkage (SAIL) databank. METHOD: An OMEQe measure was developed and used to describe trends in opioid burden over the study period. OMEQe burden was stratified by eight drug groups, which was based on usage and deprivation. RESULTS: An estimated 643 436 843 milligrams (mg) OMEQe was issued during the study. Annual number of prescriptions increased 44% between 2005 and 2015, while total daily OMEQe per 1000 population increased by 95%. The most deprived areas of Wales had 100 711 696 mg more OMEQe prescribed than the least deprived over the study period. CONCLUSION: Over the study period, OMEQe burden nearly doubled, with disproportionate OMEQe prescribed in the most deprived communities. Using OMEQe provides an alternative measure of prescribing and allows easier comparison of the contribution different drugs make to the overall opioid burden.

Rapid cancer diagnosis for patients with vague symptoms: a cost-effectiveness study.

BACKGROUND: A pilot rapid diagnosis centre (RDC) allows GPs within targeted clusters to refer adults with vague and/or non-specific symptoms suspicious of cancer, who do not meet criteria for referral under an urgent suspected cancer (USC) pathway, to a multidisciplinary RDC clinic where they are seen within 1 week. AIM: To explore the cost-effectiveness of the RDC compared with standard clinical practice. DESIGN AND SETTING: Cost-effectiveness modelling using routine data from Neath Port Talbot Hospital, Wales. METHOD: Discrete-event simulation modelled a cohort of 1000 patients from referral to radiological diagnosis based on routine RDC and hospital data. Control patients were those referred to a USC pathway but then downgraded. Published sources provided estimates of patient quality of life (QoL) and pre-diagnosis anxiety. The model calculates time to diagnosis, costs, and quality-adjusted life years (QALYs), and estimates the probability of the RDC being a cost-effective strategy. RESULTS: The RDC reduces mean time to diagnosis from 84.2 days in usual care to 5.9 days if a diagnosis is made at clinic, or 40.8 days if further investigations are booked during RDC. RDC provision is the superior strategy (that is, less costly and more effective) compared with standard clinical practice when run near or at full capacity. However, it is not cost-effective if capacity utilisation drops below 80%. CONCLUSION: An RDC for patients presenting with vague or non-specific symptoms suspicious of cancer in primary care reduces time to diagnosis and provides excellent value for money if run at ≥80% capacity.

Realist evaluation of cancer rehabilitation services in South Wales (REEACaRS): a mixed methods study protocol.

INTRODUCTION: Long-term and late effects of cancer treatments can cause functional limitations and reduce quality of life. Cancer rehabilitation services, which can comprise physical exercise, psychological support and educational interventions depending on the individual's needs, have been found to have a positive effect on health-related quality of life worldwide. However, accessibility or the lack of awareness on available help can act as barriers and influence the uptake of services, resulting in people having unmet rehabilitation needs. In Wales, UK, 41% of people, who have had health and social care needs resulting from cancer and its treatments, reported that they did not receive care when needed. The reason for this lack of support has not yet been fully investigated. The aim of this study is to investigate the conditions in which cancer rehabilitation services work and their underpinning mechanisms in South Wales, UK, specifically addressing barriers, facilitators and costs. METHODS AND ANALYSIS: Realist evaluation, which explains for whom a service works in what circumstances and how through context-mechanism-outcome pattern conjunctions, will be used in three phases to investigate the conditions in which cancer rehabilitation services work and their underpinning mechanisms. Phase 1 will be secondary analysis of a cancer rehabilitation database from a local Health Board to give context to who are accessing rehabilitation. Phase 2 will be thematic analysis of face-to-face, semistructured rehabilitation participant (n=20) and healthcare professional (n=20) interviews to explore the mechanisms of how cancer rehabilitation works. Phase 3 will be two case studies and cost-consequences analysis of cancer rehabilitation services. ETHICS AND DISSEMINATION: This study received favourable ethical opinion from London South-East Research Ethics Committee (17/LO/2123) in December 2017. This project is part of the author's PhD thesis and it is expected that the findings will be disseminated in academic journals and at local and international conferences.

Quality of life, recovery and decision-making: a mixed methods study of mental health recovery in social care.

PURPOSE: Mental health care is a complex system that includes social care organisations providing support for people with continuing needs. The relationship over time between decisional conflict, social support, quality of life and recovery outcomes across two time periods for people experiencing mental health problems in receipt of social care was investigated. METHODS: This is a mixed methods study comprised of a quantitative survey at two time points using measures of decisional conflict, social support, recovery and quality of life in a random sample (n = 122) using social care services in Wales, UK. In addition, 16 qualitative case studies were developed from data collected from individuals, a supportive other and a care worker (n = 41) to investigate trajectories of care. Survey responses were statistically analysed using SPSS and case study data were thematically analysed. RESULTS: Participants reported increasing decisional conflict and decreasing social support, recovery and quality of life over the two time points. Linear regression indicated that higher recovery scores predict better quality of life ratings and as ratings for social support decline this is associated with lower quality of life. Correlational analysis indicated that lower decisional conflict is associated with higher quality of life. Thematic analysis indicated that 'connectedness and recovery' is a product of 'navigating the system of care' and the experience of 'choice and involvement' achieved by individuals seeking help. CONCLUSIONS: These results indicate that quality of life for people experiencing mental health difficulties is positively associated with social support and recovery and negatively associated with decisional delay.

Learning of pitch and time structures in an artificial grammar setting.

Despite the empirical evidence for the power of the cognitive capacity of implicit learning of structures and regularities in several modalities and materials, it remains controversial whether implicit learning extends to the learning of temporal structures and regularities. We investigated whether (a) an artificial grammar can be learned equally well when expressed in duration sequences as when expressed in pitch sequences, (b) learning of the artificial grammar in either duration or pitch (as the primary dimension) sequences can be influenced by the properties of the secondary dimension (invariant vs. randomized), and (c) learning can be boosted when the artificial grammar is expressed in both pitch and duration. After an exposure phase with grammatical sequences, learning in a subsequent test phase was assessed in a grammaticality judgment task. Participants in both the pitch and duration conditions showed incidental (not fully implicit) learning of the artificial grammar when the secondary dimension was invariant, but randomizing the pitch sequence prevented learning of the artificial grammar in duration sequences. Expressing the artificial grammar in both pitch and duration resulted in disproportionately better performance, suggesting an interaction between the learning of pitch and temporal structure. The findings are relevant to research investigating the learning of temporal structures and the learning of structures presented simultaneously in 2 dimensions (e.g., space and time, space and objects). By investigating learning, the findings provide further insight into the potential specificity of pitch and time processing, and their integrated versus independent processing, as previously debated in music cognition research. (PsycINFO Database Record

The influence of temporal regularities on the implicit learning of pitch structures.

Implicit learning is the acquisition of complex information without the intention to learn. The aim of this study was to investigate the influence of temporal regularities on the implicit learning of an artificial pitch grammar. According to the dynamic attending theory (DAT) external regularities can entrain internal oscillators that guide attention over time, inducing temporal expectations that influence perception of future events. In the present study, the presentation of the artificial pitch grammar in the exposure phase was temporally either regular or irregular for one of two participant groups. Based on the DAT, it was hypothesized that the regular temporal presentation would favour implicit learning of tone structures in comparison to the irregular temporal presentation. Results demonstrated learning of the artificial grammar for the group with the regular exposure phase and partial learning for the group with the irregular exposure phase. These findings suggest that the regular presentation helps listeners to develop perceptual expectations about the temporal occurrence of future tones and thus facilitates the learning of the artificial pitch grammar.

Cost-effectiveness of different strategies to manage patients with sciatica.

The aim of this paper is to estimate the relative cost-effectiveness of treatment regimens for managing patients with sciatica. A deterministic model structure was constructed based on information from the findings from a systematic review of clinical effectiveness and cost-effectiveness, published sources of unit costs, and expert opinion. The assumption was that patients presenting with sciatica would be managed through one of 3 pathways (primary care, stepped approach, immediate referral to surgery). Results were expressed as incremental cost per patient with symptoms successfully resolved. Analysis also included incremental cost per utility gained over a 12-month period. One-way sensitivity analyses were used to address uncertainty. The model demonstrated that none of the strategies resulted in 100% success. For initial treatments, the most successful regime in the first pathway was nonopioids, with a probability of success of 0.613. In the second pathway, the most successful strategy was nonopioids, followed by biological agents, followed by epidural/nerve block and disk surgery, with a probability of success of 0.996. Pathway 3 (immediate surgery) was not cost-effective. Sensitivity analyses identified that the use of the highest cost estimates results in a similar overall picture. While the estimates of cost per quality-adjusted life year are higher, the economic model demonstrated that stepped approaches based on initial treatment with nonopioids are likely to represent the most cost-effective regimens for the treatment of sciatica. However, development of alternative economic modelling approaches is required.

Rhythmic context modulates foreperiod effects.

Two experiments examined hypotheses about the roles of probabilistic uncertainty and rhythmic context on attentional preparation as reflected by choice response times (RTs) to the final tone of auditory sequences. Nonisochronous sequences with tone timings either arranged metrically or scrambled were linked with one of three different sequence-final time intervals, or foreperiods (FPs), which varied randomly from trial to trial. Two primary results emerged. First, RTs were faster to target tones ending metrical rhythms than to targets ending scrambled rhythms. Second, metrical contexts elicited RTs that increased with FP duration, whereas scrambled contexts elicited RTs that often decreased with FP duration, despite equivalent variability of time intervals in metrical and scrambled contexts. The results suggest that time relations implied by metrical rhythms systematically modulate preparatory responses to sequence-final FPs.

Supporting informed decision making for prostate specific antigen (PSA) testing on the web: an online randomized controlled trial.

BACKGROUND: Men considering the prostate specific antigen (PSA) test for prostate cancer, an increasingly common male cancer, are encouraged to make informed decisions, as the test is limited in its accuracy and the natural history of the condition is poorly understood. The Web-based PSA decision aid, Prosdex, was developed as part of the UK Prostate Cancer Risk Management Programme in order to help men make such informed decisions. OBJECTIVES: The aim of this study was to evaluate the effect of the Web-based PSA decision aid, Prosdex, on informed decision making. METHODS: A Web-based randomized controlled trial was conducted in South Wales, United Kingdom. Men aged 50 to 75 who had not previously had a PSA test were randomly allocated to two intervention and two control groups. Participants in the intervention groups either viewed Prosdex or were given a paper version of the text. The main outcome measures were the three components of informed decision making: (1) knowledge of prostate cancer and PSA, (2) attitude toward PSA testing, (3) behavior using a proxy measure, intention to undergo PSA testing. Decisional conflict and anxiety were also measured as was uptake of the PSA test. Outcomes were measured by means of an online questionnaire for the Prosdex group, the paper version group, and one of two control groups. Six months later, PSA test uptake was ascertained from general practitioners' records, and the online questionnaire was repeated. Results are reported in terms of the Mann-Whitney U-statistic divided by the product of the two sample sizes (U/mm), line of no effect 0.50. RESULTS: Participants were 514 men. Compared with the control group that completed the initial online questionnaire, men in the Prosdex group had increased knowledge about the PSA test and prostate cancer (U/mn 0.70; 95% CI 0.62 - 0.76); less favourable attitudes to PSA testing (U/mn 0.39, 95% CI 0.31 - 0.47); were less likely to undergo PSA testing (U/mn 0.40, 95% CI 0.32 - 0.48); and had less decisional conflict (U/mn 0.32, 95% CI 0.25 - 0.40); while anxiety level did not differ (U/mn 0.50, 95% CI 0.42 - 0.58). For these outcomes there were no significant differences between men in the Prosdex group and the paper version group. However, in the Prosdex group, increased knowledge was associated with a less favourable attitude toward testing (Spearman rank correlation [rho] = -0.49, P < .001) and lower intention to undergo testing (rho = -0.27, P = .02). After six months, PSA test uptake was lower in the Prosdex group than in the paper version and the questionnaire control group (P = .014). Test uptake was also lower in the control group that did not complete a questionnaire than in the control group that did, suggesting a possible Hawthorne effect of the questionnaire in favour of PSA testing. CONCLUSIONS: Exposure to Prosdex was associated with improved knowledge about the PSA test and prostate cancer. Men who had a high level of knowledge had a less favourable attitude toward and were less likely to undergo PSA testing. Prosdex appears to promote informed decision making regarding the PSA test. TRIAL REGISTRATION: ISRCTN48473735; http://www.controlled-trials.com/ISRCTN48473735 (Archived by WebCite at http://www.webcitation.org/5r1TLQ5nK).

Shared decision-making in cardiology: do patients want it and do doctors provide it?

OBJECTIVE: Doctors should involve their patients in making decisions about their care. We studied patients with heart disease to assess if shared decision-making occurs and to study factors that predict patients' choices or influence cardiologists' behaviour. METHODS: 85 patients attending for arteriography were assessed to elicit preferred involvement in decision-making, perception of involvement, and confidence in the decision. RESULTS: 40% of patients wished to be involved in decisions. Preferences were unrelated to demographic factors. Cardiologists involved patients more in decisions concerning severe disease (p=0.056). Involvement varied between cardiologists (p=0.001). The mean duration of consultations was 5.5 min. Patients' confidence in decisions correlated with duration (p=0.001), explicit reference to a decision that needed to be made (p=0.0026), and perceived, but not observed, involvement in decision-making (p=0.05). CONCLUSION: This study highlighted the complexity of doctor-patient communication. Irrespective of preferences for involvement, patients were more confident in decisions in which they perceived more involvement or which were the products of longer consultations. PRACTICE IMPLICATIONS: Patients' confidence in clinical decisions can be increased by increasing consultation length and increasing their perception of involvement. Patients perceive more involvement in decisions when doctors specifically identify the need for treatment decisions early in the consultation.

The role of accent salience and joint accent structure in meter perception.

Previous research indicates that temporal accents (TAs; accents due to time changes) play a strong role in meter perception, but evidence favoring a role for melodic accents (MAs; accents due to pitch changes) is mixed. The authors claim that this mixed support for MAs is the result of a failure to control for accent salience and addressed this hypothesis in Experiment 1. Listeners rated the metrical clarity of 13-tone melodies in which the magnitude and pattern of MAs and TAs were varied. Results showed that metrical clarity increased with both MA and TA magnitude. In Experiment 2, listeners were asked to rate metrical clarity in melodies with combinations of MA and TA patterns to allow the authors to ascertain whether these two accent types combined additively or interactively in meter perception. With respect to the additive or interactive debate, the findings highlighted the importance of (a) accent salience, (b) scoring methods, and (c) conceptual versus statistical interpretations of data. Implications for dynamic attending and neuropsychological investigations are discussed.

The time of our lives: life span development of timing and event tracking.

Life span developmental profiles were constructed for 305 participants (ages 4-95) for a battery of paced and unpaced perceptual-motor timing tasks that included synchronize-continue tapping at a wide range of target event rates. Two life span hypotheses, derived from an entrainment theory of timing and event tracking, were tested. A preferred period hypothesis predicted a monotonic slowing of a preferred rate (tempo) of event tracking across the life span. An entrainment region hypothesis predicted a quadratic profile in the range of event rates that produced effective timing across the life span; specifically, age-specific entrainment regions should be narrower in childhood and late adulthood than in midlife. Findings across tasks provide converging support for both hypotheses. Implications of these findings are discussed for understanding critical periods in development and age-related slowing of event timing.